Management Of Benign Ureteral Strictures Research Articles

MP22-13 DOUBLE URETERAL STENT PLACEMENT REDUCES RESTENOSIS AFTER INCISION AND DILATATION FOR URETERAL STENOSIS

INTRODUCTION AND OBJECTIVE: Laser incision (laser endoureterotomy: LE) and balloon dilatation (BD) are the treatments for ureteral strictures measuring ≤20 mm; however, these treatments are associated with a high risk of postoperative restenosis. Endoscopic management of benign ureteral strictures has been described in the adult literature with failure rates of 12% to 38%. Therefore, this study aimed to investigate the effectiveness of a novel method to place double ureteral stents after LE and BD. METHODS: In total, 10 patients who underwent endoscopic surgery for ureteral stenosis from January 2016 to March 2019 were included. All stenoses were iatrogenic rather than congenital. In LE, the stenosis site, including 2 mm before and after the site, was incised using a laser until the fat tissue outside the ureter was visible. A flexible ureteroscope was used for upper ureteral stenosis and a semi-rigid ureteroscope was used for middle or lower ureteral stenosis. In BD, the stenosis site was dilated with a balloon up to 15 Fr. In all cases, two 4.7-Fr ureteral stents were placed and removed 4–8 weeks after surgery. The improvement of hydronephrosis, surgical parameters, and complications were evaluated. RESULTS: The stenosis site was confirmed in the upper ureter in six patients; in the middle ureter in three patients; and in the lower ureter in one patient, with an average distance of 9.7 ± 5.6 mm. Preoperative hydronephrosis was grade G1 in one patient, grade G2 in one patient, grade G3 in four patients, grade G4 in four patients, and improved in nine patients (90%) 3 months after surgery. The average duration of surgery was 111 ± 21 minutes, and no surgical complications over grade 3 were observed. The average duration of hospital stay was 4.1 ± 0.5 days. The mean follow-up period was 661 ± 405 days, and no restenosis was observed in any of the eight patients. CONCLUSIONS: Placement of double ureteral stents after surgery for ureteral stenosis was effective. Source of Funding: none

Evaluation of risk factors and treatment options in patients with ureteral stricture disease at a single institution.

Ureteral strictures are a significant cause of morbidity and mortality, resulting in potential kidney damage requiring several surgical procedures. Non-malignant causes include radiation, trauma from calculi impaction, pelvic surgery, or ureteroscopy (URS). We identified risk factors in our patients with ureteral strictures and the success of their treatment outcomes. A retrospective chart review of 25 patients with 29 ureteral strictures was performed to determine the success of their treatment. Twenty-five (25) patients with 29 benign ureteral strictures were identified. Most cases (60%) were caused by impacted stones where the median stone size was 1.15 cm (0.37-1.8 cm). Intervention for stones prior to stricture development included shockwave lithotripsy, URS, and percutaneous nephrolithotomy. Five patients with strictures from impacted stones had ureteric complications during stone treatment including perforation +/- urinoma (n=3), fractured guidewire left in situ (n=1), and ureteric orifice resection (n=1). Other stricture etiologies included radiation (28%) and endometriosis (4%). Treatment modalities used included ureteroureterostomy (n=2), ureteral re-implant (n=3), urinary diversion (n=3), autotrasplant (n=1), laser endoureterotomy +/- balloon dilation (n=8), nephrectomy (n=2), balloon dilation +/- stent (n=3), ureterovesical junction (UVJ) resection + stent (n=1), chronic stent changes (n=4), or surveillance (n=3). Our evaluation highlights important principles. Patients with complicated ureteroscopies or severely impacted calculi warrant close followup with imaging after stone treatment due to possibility of rapid renal deterioration from stricture formation. Radiation-induced strictures are difficult to manage, possibly requiring subsequent urinary diversion. Finally, endoscopic management of benign ureteral strictures via balloon dilation and laser endoureterotomy is an excellent choice in properly selected patients, with opportunity for subsequent salvage treatments if needed.

Abstract No. 163: Retrievable metal stents in management of benign ureteric strictures: A feasibility study

To evaluate the safety and efficacy of retrievable stent in management of persistent benign ureteric stricture. Eight patients with post-operative ureteric stricture that did not respond to balloon dilatation were included in the study. Nine retrievable wall flex covered metal stent were placed for at least 4 weeks to keep stricture patent. The stents were removed using endoscopy forceps percutaneously after 4 weeks and stricture was assessed for response to treatment. Eight stents were placed by antegrade approach through existing nephrostomy access and one stent was placed through retrograde approach through ileal conduit. Technical success was achieved in five of the six patients whom retrieval was attempted. Four were removed percutaneously by antegrade approach through the nephrostomy access and one stent was placed and removed by retrograde approach through the ileal conduit. In two patients stent could not be retrieved by antegrade approach in the interventional radiology suite due to fracture of retrieval loop and crimpling of the stent. One of stent was left in renal pelvis and it was removed via the percutaneous route in the operating room using rigid nephroscope and rigid forceps. The other patient stent was left in ureter and NU catheter was placed through the stent. Two patients had no hydronephrosis after removal of stent in follow up imaging, one patient has persistence of stricture and one patient with transplant kidney and anastomotic stricture developed complete occlusion of the lower ureter. One patient was lost to follow-up however immediate post removal nephrostogram shows significant improvement. Retrievable metal stents can be placed across ureteric stricture (100%) and retrieved (83.3%) by both antegrade and retrograde approach with high success rate. Improvement of ureteric stricture was observed in three patients, persistence of stricture in one patient and worsening in one patient. Patients with uretero-enteric anastomostic stricture following radical cystectomy responded well however there was worsening of stricture in a transplant patient with ureteric anastomotic stricture.

Management of Benign Ureteral Strictures in the Endoscopic Era

During the past decade, endoscopic management has emerged as the first-line treatment of benign ureteral strictures. We reviewed our experience with the management of benign ureteral strictures to determine the success rate of endoscopic surgery in a contemporary series and assessed the viability of surgical reimplantation in the modern era. We identified 75 patients with a diagnosis of ureteral stricture between 2000 and 2005 via electronic medical records search and excluded those with completely obliterated, external compressive, malignant, or ureteroenteric strictures, ureteropelvic junction obstruction, and those with follow-up less than 2 months. Thirty-four patients who were treated endoscopically (balloon dilation and/or holmium laser endoureterotomy) were identified. Mean stricture length in each patient was 1.6 +/- 1 cm (range 0.5-4 cm), and the mean number of procedures per patient was 1.7 +/- 0.8. Endoscopic success was achieved in 29 (85%), while 5 (15%) patients experienced endoscopic management failure and ultimately needed ureteral reimplantation. When comparing the endoscopically treated and reimplant groups, there was no significant difference in mean stricture length (1.38 +/- 1.13 vs 2 +/- 1.1 cm, P = 0.14), yet mean number of procedures performed (1.41 +/- 0.85 vs 3.6 +/- 1.5; P = 0.002) reached statistical significance. There were no clinical or radiographic signs of obstruction in 100% of patients who received endoscopic therapy only and 100% of patients who needed open surgical management at a mean follow-up of 25.2 +/- 19.3 and 7.7 +/- 3.2 months, respectively. Endoscopic surgery is clearly a successful primary treatment modality in the management of benign ureteral strictures with minimal morbidity. In the modern era of endoscopic surgery, however, ureteral reimplantation remains a viable option in treating the small subset of patients with benign ureteral strictures for whom endoscopic management fails.

Holmium: Yttrium-Aluminum-Garnet Laser Endoureterotomy for Benign Ureteral Strictures: a Single-Centre Experience

Purpose: This study aimed to report the results of endoureterotomy for benign ureteral strictures using the holmium: yttrium-aluminum-garnet laser.Material and methods: Nineteen patients (8 men and 11 women, mean age 51.47 years) underwent holmium: yttrium-aluminum-garnet laser endoureterotomy for benign ureteral strictures (8 proximal, 3 middle, and 8 distal) using semirigid ureteroscopy and 360-μm fibre at 1.2 J/pulse and 10 Hz. After completion of the incision, a 7-Fr double-J ureteral stent was left for 6 weeks. Thereafter, the patients were followed-up by ultrasound and/or intravenous urography at 36 monthly intervals.Results: Success was defined as the absence of symptoms plus radiographic resolution of obstructions as assessed by diuretic renography and/or intravenous urography. With a mean follow-up of 40.2 months, success was achieved in 10 (52.6%) of the 19 patients. Nine patients developed recurrent strictures and were considered treatment failures. The stricture length and severity of hydronephrosis correlated with successful outcome, but gender, aetiology, side and location of strictures did not predict outcome.Conclusions: Although endoureterotomy using a holmium: yttrium-aluminum-garnet laser has an equivocal outcome, the procedure is recommended as a safe, less invasive therapeutic option for the initial management of benign ureteral strictures.

Management of Benign Ureteral Strictures Following Radical Cystectomy and Urinary Diversion for Bladder Cancer

Ureteral obstruction due to benign strictures is a significant complication of radical cystectomy and urinary diversion for bladder cancer that can lead to renal function loss and infection related morbidity. Treatment may be performed surgically or with minimally invasive techniques. We describe the 10-year experience at our department with various treatment modalities for post-cystectomy benign strictures. The study group consisted of 28 patients treated for benign ureteral strictures following radical cystectomy for bladder cancer. Their medical records were reviewed for clinical presentation, diagnostic procedures, treatment and long-term outcome. The study group represented 12.7% of all 221 patients treated at our department with radical cystectomy for bladder cancer in 1994 to 2004. Ureteral strictures were asymptomatic in 71.4% of cases. Median time to diagnosis was 7.0 months and 75% of the patients were diagnosed within year 1 after cystectomy. Treatment consisted of stenting, dilation and open surgical revision with removal of the strictured segment and reanastomosis. Median followup was 62.5 months. The stenting procedures served as the long-term definitive treatment in 45% of cases, whereas balloon dilation uniformly failed. Although open surgical revision was technically challenging, it had a long-term success rate of 93%. Benign ureteral strictures commonly occur during postoperative year 1 and they are usually asymptomatic. Early diagnosis and prompt drainage are required to prevent consequent renal parenchymal loss and infectious complications. Although minimally invasive procedures are viable treatment alternatives, open surgical revision is still the preferred long-term definitive treatment.

Endoscopic Treatment of Benign Ureteral Strictures

The traditional choice of procedure for treatment of ureteral stricture is open surgical repair. Advances in endourology have provided the urological surgeon with an alternative to open surgery for the treatment of benign ureteral stricture. Twenty-seven benign ureteral strictures in 24 patients were treated by the endourological method. Twelve endoureterotomies were performed using a cold knife via a 9.5Fr Storz ureteroscope and 15 high pressure balloon dilations were performed. The ureters were stented with 7 Fr double-J stents for 6 weeks. The success rate was 9/12 (75%) in the endoureterotomy group and 9/15 (60%) in the balloon dilation group after follow-up for more than 6 months. Endoscopic treatment of ureteral strictures appeared to be a safe and reasonably effective modality for the treatment of ureteral strictures, especially for the short type that are non-ischaemic in origin and not associated with radiation therapy. Endourological treatment of ureteral strictures is the procedure of choice for initial management of benign ureteral strictures and has high success rates and fewer complications.

The self-expanding metallic ureteric stent in the long-term management of benign ureteric strictures.

To evaluate and assess the long-term complications of using the thermo-expandable, nickel-titanium alloy stent (Memokath 051, Engineers & Doctors A/S, Hornbaek, Denmark) for managing benign ureteric strictures. Over a 3-year period, 13 Memokath stents were inserted in 11 patients (mean age 58 years, range 35-85) with 12 lower ureteric strictures. The cause of the stricture was benign in all cases, i.e. radiation fibrosis in three, retroperitoneal fibrosis, ischaemic uretero-ileal anastomosis and scarring after ureteroscopy in two each, and diathermy damage, extraluminal endometriosis and stone passage in one each. Four stents were 9 F with proximal expansion to 17 F and the other nine used were 10.5 F with proximal expansion to 20 F. The patients were followed for a mean (range) of 18 (1.5-33) months. No complications or side-effects occurred with nine stents; four stents were removed at a mean (range) of 16.3 (4-33) months. Three of these had become encrusted, two of which had been placed in patients who had either a history of stone disease or recurrent urinary tract infection. The other stent had migrated. The Memokath stent appears to have a useful role in managing benign ureteric strictures, but it must be closely monitored in patients who are predisposed to encrustation.

THE ORTHOTOPIC KOCK ILEAL NEOBLADDER: FUNCTIONAL RESULTS, URODYNAMIC FEATURES, COMPLICATIONS AND SURVIVAL IN 166 MEN

We report our experience with 166 patients who underwent radical cystectomy and orthotopic bladder substitution with the ileal Kock neobladder between February 1990 and January 1999. We classified complications as early (3 months or less postoperatively) and late. Continence was assessed by patient interview, the need to use protective devices and provocative incontinence testing. Neobladder function was evaluated by uroflowmetry, post-void residual urine volume measurement and enterocystometry, and renal function was assessed by 51creatinine ethylenediaminetetraacetic acid clearance. There were no perioperative deaths. However, 52 early complications developed in 39 patients (23.5%) and 73 late complications in 62 (37.4%). The rate of early and late complications associated with the urinary tract was 11.5% and 23.5% with abdominal reoperation rates of 1.8% and 2.4%, respectively, due to these complications. At 3 and 5 years the risk of stone formation on the metallic staples was 18% and 34%, and the risk of B12 deficiency was 30% and 33%, respectively. One patient (0.6%) underwent reoperation for ureteral anastomotic stricture. Anterior urethral stricture in 5 cases (3%) was caused by recurrence in 1 and urethral anastomotic stricture in 1 also resulted from recurrent disease. Daytime continence was reported by 97% and 100% of our patients at 1 and 5 years, respectively. Provocative incontinence testing confirmed this level of daytime continence. Overall 75% of patients reported nighttime continence at 1 year and 94% at 5 years. The need for a nighttime protective device decreased with time. At 1 versus 3 years 39.8% versus 45.9% of patients used no protection, 29.7% versus 39.2% used a sanitary pad and 30.5% versus 14.9% used a condom device. Enterocystometric capacity and subtracted maximum reservoir pressure remained remarkably uniform at 456 versus 411 ml. and 47 versus 50 cm. water 6 months and 5 years postoperatively, respectively. Nevertheless, median post-void residual urine volume increased from 20 ml. at 6 months to 40 ml. at 5 years with an increased prevalence of patients requiring intermittent catheterization due to post-void residual urine greater than 100 ml. from 16% at 6 months to 44% at 5 years. 51Creatinine ethylenediaminetetraacetic acid clearance remained unchanged. There was a substantial 5-year survival advantage for the subpopulation with stage pT3a or less, pN0 tumors (94% versus 51%, p <0.001). Radical cystectomy and orthotopic bladder substitution with the Kock ileal neobladder may be performed with an acceptable complication rate and good functional results. The probability of survival was considerably higher for patients with tumor confined to the bladder. Consequently we believe that early aggressive treatment should be considered in those with invasive disease, and reconstruction with orthotopic bladder substitution may encourage patients to accept radical surgery.

Endourologic management of benign ureteral strictures with and without compromised vascular supply

Objectives. To retrospectively assess the efficacy of balloon dilation, endopyelotomy/ureterotomy, and stenting alone in the management of benign ureteral strictures with intact or compromised vascular supply. Methods. One hundred fourteen patients with benign ureteral strictures were assessed after at least a 2-year follow-up (range 2 to 16 years, mean 6.3). Balloon dilation was performed in 81, endopyelotomy/ureterotomy with temporary stenting in 27, and ureteral stenting alone in 6 patients. Ureteral strictures were divided into strictures with intact or with compromised vascular supply. Results. Balloon dilation was successful in short ureteral strictures with intact vascular supply in 33 of 37 (89.2%), but only in 3 of 8 (37.5%) long ureteral strictures and in 1 of 2 (50%) recurrent ureteropelvic junction strictures. Balloon dilation was less successful when the vascular supply was compromised in 2 (40%) of 5 short strictures, 1 (16.7%) of 6 long strictures, and 2 (33.3%) of 6 recurrent ureteropelvic junction strictures. Endopyelotomy/ureterotomy was successful in 17 (89.5%) of 19 strictures with compromised vascular supply. Conclusions. Balloon dilation is recommended for management of short strictures with intact vascular supply. Endoureterotomy with stenting is recommended for all long ureteral strictures, for ureteropelvic junction stenoses, and for short ureteral strictures with compromised vascular supply and benign underlying etiology.

Management of Benign Ureteral Strictures: Open Surgical Repair or Endoscopic Dilation?

We reviewed 20 cases of ureteral strictures, 15 of which were secondary to ureteral trauma. Of the patients 6 were managed initially by open repair and 14 underwent endoscopic manipulation. All 6 open repairs were successful, compared to 9 of the 14 patients who underwent endoscopic dilation of the ureteral stricture. Of the 5 failures 3 were due to the inability to cannulate the strictured ureter with a guide wire and 2 failed to respond to balloon dilation. Of these 5 patients 4 were treated successfully by an open operation. There were no serious intraoperative or postoperative complications. The average hospitalization was less for the endoscopic group (2.1 days) compared to the open surgical group (8.3 days). Followup ranged from 6 to 48 months.

Percutaneous Management of Benign Ureteral Strictures and Fistulas

The percutaneous methods of management of benign ureteral strictures or fistulas have developed as a natural evolution of percutaneous nephrostomy and angiographic techniques. We review our 5-year experience, which includes 18 patients with 19 benign ureteral strictures and 12 patients with ureteral fistulas. In the majority of the patients the ureteral strictures occurred at sites of surgical reconstruction or endoscopic manipulation. All fistulas resulted from surgical injury. In 10 of the 12 patients (82 per cent) the fistulas healed without development of a stricture or need for further intervention. Patients with short ureteral strictures had a high incidence of success and they usually were the best candidates for percutaneous manipulation. The longer strictures usually were of longer duration and they were less likely to be managed successfully percutaneously. Failure of percutaneous dilation did not impede subsequent surgical management. Percutaneous management often is a reasonable initial step in the treatment of ureteral strictures and fistulas.